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COLORADO DIVISION OF WATER RESOURCES <br />Form No. DEPARTMENT OF NATURAL RESOURCES <br />GWS-65 1313 Sherman St. Rm. 818 Denver CO 80203 <br />08/23/01 Phone-info: (303)866-3587 Main: (303)866-3581 <br />Fax: (303) 866-2223 http://www.waterstate.co.us <br />PETITION FOR REINSTATEMENT OF A WELL <br />PERMIT PURSUANT TO C.R.S. 37-90-137(3)(c) <br />Used for late filing Statements of Beneficial Use or Notices of Well Completion after the permit expiration <br />date for well permits issued pursuant to C.R.S. 37-90-137(2), (4) and (7) <br />On ,the Colorado State Engineer issued well permit number <br />Insert date the permit was issued <br />I (We) failed to submit evidence of beneficial use, if the permit was issued per CRS 37-90-137(2) or CRS 37-90- <br />137(7), or a notice of well completion if the permit issued per CRS 37-90-137(4), prior to the expiration date of the <br />well permit due to the following reasons: <br />1 (We) hereby petition the State Engineer to find that the above reasons constitute excusable neglect, inadvertence <br />or mistake and accept the evidence attached hereto in accordance with applicable Colorado Revised Statutes. <br />Further, I (we) say that I (we) have read the statements made herein and that the same are true of my (our) own <br />knowledge. <br />Signature <br />Signature <br />Date <br />Date <br />